STCW Medical Screening Form

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STCW Medical Screening Form

Please complete the following Medical Questionnaire. We require this information in order to book your STCW-10 Training.

STCW MEDICAL SCREENING FORM

- Step 1 of 7

Name of Learner *

Have you been hospitalized or been under a surgical intervention within the last 12 months? *

Yes
No

If yes, what and when?

Do you have any physical disability? *

Yes
No

If yes, please describe in full.

Are you presently on light duty because of a medical condition? *

Yes
No

If yes, what and when?

Did you have any disease, altered state of health or any accident in past 12 months? *

Yes
No

If yes, what and when?

Have you been treated or being in the care of a doctor in the last 12 months for any medical condition that would require a doctor’s release? *

Yes
No

If yes, what and when?

Do you have any phobias such as Height, Enclosed Spaces, Water, etc. *

Yes
No

If yes, please describe in full.

Are you suffering from any physical or physiological condition not mentioned that could affect your participation in any of the training physical activities? *

Yes
No

If yes, please describe in full.

Do you have any anxiety /Panic Attacks that could prevent you from safely completing this training? *

Yes
No

If yes, please describe in full.

Have you ever had epilepsy/ seizures / fainting / “blackout”? *

Yes
No

If yes, what and when?

Have you ever had a head injury? *

Yes
No

If yes, what and when?

Do you have any problems with headaches / balance / hearing? *

Yes
No

If yes, please describe in full.

Are your ears sensitive to water? *

Yes
No

Do you have shortness of breath/breathing difficulties? *

Yes
No

If yes, please describe in full.

Have you suffered chest pains? *

Yes
No

If yes, what and when?

Do you have a history of displaced joints (bad knee, bad back etc.)? *

Yes
No

If yes, please describe in full.

Are you currently under any treatment or any kind of medication? *

Yes
No

If yes, please describe in full.

Have you taken any medication in the past 24 hours that could impair your ability during this training? *

Yes
No

If yes, please describe in full.

Do you suffer or have you suffered from any of the following? Select any/all that are applicable. *

Respiratory Diseases (allergies, asthma, bronchitis, tuberculosis or other)
CARDIOVASCULAR diseases(heart attack, angina, thrombosis, phlebitis or other)
DIGESTIVE SYSTEM Diseases (gastritis, ulcers, hepatitis B/C or other diseases
URINARY SYSTEM Diseases (infection, kidney stones or other)
METABOLIC Diseases (diabetes, obesity, anemia or other)
BONE SYSTEM Diseases (arthritis, bone fracture, dislocation, slipped disc, rheumatism or other)
NEUROLOGICAL Diseases (epilepsy, depression or other)
SKIN diseases (ringworm, folliculitis, herpes or other)
EYE Diseases (myopia or other)
High blood pressure
None of The Above

If any of the above are applicable, please describe in full what your condition is, when diagnosis was made and what medication/medical intervention is being used to treat the condition.

Please list any other medical problems or recent injuries.

English Comprehension (not first language)

Yes I need Help with Translation
No Help Required

English Literacy

Yes I need Help with Translation
No Help Required

Special Religious Considerations

Yes I Have a Religious Consideration
No Help Required

Disabilities that could prevent the successful completion of all aspects of the course

Yes I need Help
No Help Required

If 'Yes' to any of the above, please provide context

Please Select Today's Date *

Signature *

If you need any further info or have any enquiries please email: courses@syta.co.za or call +27 21 418 4074 / +27 61 107 0533

Contact Us

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Phone +27 21 418 4074
Mobile +27 61 107 0533

Academy

14 W Quay Road
V&A Waterfront, Cape Town
South Africa, 8002

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